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If an insurance company denies your claim for accidental death insurance or life insurance benefits for the loss of a loved one claiming that “intoxication” or “driving while intoxicated” caused the death, do not give up.
That’s exactly what they want you to do, even though you may be legally entitled to recover full benefits.
No matter how long someone pays insurance premiums to protect their family, insurance companies care about profits, and paying claims doesn’t help with their profits.
Fortunately, appealing the claim properly to the insurance company (known as an “administrative appeal”), and filing a lawsuit in federal court can result in your denied claim being approved for full benefits. The court can even award you your attorney fees for having to fight an unfair denial of benefits.
It could happen to you. It’s happened to many of my clients before they retained a lawyer. Good people, family breadwinners, pay insurance companies thousands of dollars for years to protect themselves and their loved ones against financial ruin in the event of their death or disability.
Then when tragedy does strike, and families desperately need the benefits, the insurance companies cheat to issue grossly unfair claim denials base on an “intoxication” exclusion or other exclusions when the facts don’t support it. They’ll even illegally withholding key evidence as CIGNA recently did to issue a bogus claim denial to my client. So they profit and thrive while abandoning families to financial disaster. The saddest part is they often get away with it.
Whether it’s a claim for life insurance or accidental death insurance benefits, don’t expect the insurance company to play fair. It won’t. It will pretend to befriend you while secretly plotting to build a case to avoid paying what you deserve. So brace yourself, you have entered an insurance war zone.
The exact language of intoxication exclusion clauses in life insurance and accidental death and dismemberment insurance policies will vary from policy to policy. But the typical intoxication exclusion will read something like the one CIGNA recently tried to say barred recovery for my client whose husband died in a car crash (the full story follows below).
In addition to any benefit-specific exclusions, benefits will not be paid for any Covered Injury or Covered Loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits Section:
5. the Covered Person’s intoxication as determined according to the laws of the jurisdiction in which the Covered Accident occurred;
6. voluntary ingestion of any narcotic, drug, poison, gas or fumes unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage.”
The insurance companies often get away with unfair claim denials because of “ERISA”, short for the federal law known as the “Employees Retirement Income Security Act.”
ERISA law governs the vast majority of insurance contracts issued to employees as part of their employment benefits, whether it’s health, disability, life or accidental death insurance. This means that anyone who files suit because of a denied claim must do so in federal court.
Most people have never even heard of ERISA unless they have endured the horrible experience of an insurance company, like CIGNA in the case described below, effectively declaring war with them for daring to seek the death or disability benefits they paid for and deserve. To make matters worse the very nature of these benefits always means the claimant victims must fight the war in the midst of a major personal and financial crisis that comes with losing a loved one.
Although ERISA was enacted to protect claimants’ rights, in reality and in practice, it actually gives insurance companies the upper hand over the victim pursuing a claim for insurance benefits.
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